Provider Demographics
NPI:1124860929
Name:LIVING WATER PSYCHIATRY PLLC
Entity type:Organization
Organization Name:LIVING WATER PSYCHIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARJORY
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERIC
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, PMHNP-BC
Authorized Official - Phone:702-854-6853
Mailing Address - Street 1:5940 S RAINBOW BLVD
Mailing Address - Street 2:SUITE 400 #783517
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-2507
Mailing Address - Country:US
Mailing Address - Phone:702-854-6853
Mailing Address - Fax:702-758-7317
Practice Address - Street 1:5940 S RAINBOW BLVD STE 400
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-2507
Practice Address - Country:US
Practice Address - Phone:702-854-6853
Practice Address - Fax:702-758-7315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty